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...everything you need to know about doing dialysis at home.
In 1943, Dr. Willem Kolff built the first hemodialysis machine. Yet it took two more decades before chronic dialysis was practical. Why? Because a new artery and vein had to be used for each treatment and then tied off afterward. Thus, only a few treatments could be done. Vascular access—a reusable way to get blood from the body to the artificial kidney and back—was what made dialysis possible.
Today, you can have a good life for many years on dialysis. But vascular access is still the biggest challenge for long-term treatment.
A vascular access uses your blood vessels. You have two types of vessels:
An ideal access would be under the skin, to reduce infection. It would be easy to reach—like a vein—but strong enough to handle the blood flow rates needed for dialysis—like an artery. It would heal itself after each needle stick, and last for decades with no problems.
* Afraid of needles? You’re not alone! Read another Home Dialysis Central article called Dialysis Needle Fear: Easing the Sting.
A fistula (surgical connection between a vein and an artery under the skin) is as close as we can get today to an ideal access. When a fistula is made, fast blood flow from the artery arterializes the vein—the layer of muscle in the vein becomes larger and stronger. This takes time.
If you will need dialysis, it’s best to get a fistula a few months ahead of time so it can mature and be ready to use. Getting a fistula at least four months before you start dialysis can reduce your risk of sepsis (blood poisoning).1 Having a fistula when you start treatment also reduces costs five-fold,2 which may save you money.
A good fistula can last for decades. Because it uses only your own artery and vein, it is less prone to infection, blood clots, and narrowing (stenosis) than other types of access. It heals itself after each needle stick. You are less likely to need hospital stays to fix a fistula. You may even live longer. In a U.S. random study of 5,507 people on dialysis, those with fistulas were significantly more likely to live than those with a graft (next best) or catheter. This was true even after adjusting for age and other illnesses.3
Fistulas are the “gold standard” for dialysis access. In fact, fistulas are so much better that Medicare has a program called Fistula First.4 This program aims to raise the U.S. rate of fistula placement and help ensure that anyone who can have a fistula will get one.
How do you know if you can have a fistula? The best way to be sure is to ask your nephrologist to refer you to a vascular (blood vessel) surgeon who does many fistulas. Then, ask the vascular surgeon to do vessel mapping—an ultrasound to look at your veins and arteries. With vessel mapping, the surgeon can make a plan for which vessels will work best. Sometimes the best plan is to transpose a large vein (move it closer to the surface of your skin). Get a second opinion if you are told that you can’t have a fistula.
It is vital that a new fistula be cannulated (have needles placed) by an experienced care team member—or that you learn to do it yourself. The fewer people who cannulate a fistula, the longer it is likely to last. Putting in your own needles hurts less, because you are distracted by what you’re doing. And, since you can feel both ends of the needles, you have the best chance of success.
There are two ways to cannulate a fistula:
While fistulas are best, they are not perfect. New fistulas can fail to mature. And sometimes a good fistula is made, but then damaged.
If a fistula is not possible, there are two other types of access:
Vascular access is what makes hemodialysis possible. If you can have a fistula, learn how to care for it—after the surgery as well as down the road. You’ll need to listen with a stethoscope each day for the bruit (whooshing noise) a healthy fistula should make, and feel for the thrill (buzzing pulse) to be sure they are the same. Changes in either can mean stenosis or a blood clot. You’ll want to check your fistula for signs of infection, like redness or warmth. And think about learning to put in your own needles—it’s the best way to help your fistula last.
For more information about fistulas, check out:
Copyright © 2006 Medical Education Institute, Inc. All rights reserved.
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